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61ECEIVIED <br /> SWRCB,January 2002 JIUN2P <br /> 4g�KV of <br /> Secondary Containment Testing Report Form <br /> E N V I R 0 N N 11,'Z-iN 17'kl I HEALTH <br /> This form is intended for use by contractors performing periodic testing of UST secondary containmen <br /> d <br /> appropriate pages ofthis form to report results for all components tested The completed formce S, <br /> printouts from tests(if applicable), should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: SN/EK Collier Road Chevron I Date of Testing: June 19,2017 <br /> Facility Address: 25651 North Highway 99,Acampo,Ca.95220 <br /> Facility Contact: Tony Singh I Phone: (209)333-1740 <br /> Date Local Agency Was Notified of Testing: 5/4/2017,by Afford-A-Test <br /> Name of Local Agency Inspector(ii(present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: R&D Compliance Testing <br /> Technician Conducting Test: Benjamin F.Duncan Jr. <br /> Credentials: ❑CSLB Licensed Contractor X SWRCB Licensed Tank Tester <br /> License Type: Tank Tester License Number:90-1120/ICC#5246802-UT ON= <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> -Caldwell Systems Piping Sumps/UDC's/Fill Riser Sumps July 30, 2017 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annular Tank#1 x El 11 [1 Dispenser Sump#7&8 x Ll 11 Ll <br /> Annular Tank#2 X El El [I Dispenser Sump#9&10 X 11 [1 11 <br /> Annular Tank#3 X F] ILI] Li Dispenser Sump#11&12 X El Ll El <br /> Secondary Pipe#1 X El El ❑ Fill Riser Sump#1 X 0 El El <br /> Secondary Pipe#2 x 0 11 El Fill Riser Sump#2 X D El El <br /> Secondary Pipe#3 X F1 El Li Fill Riser Sump#3 x F] D El <br /> -Piping Sump#I X 0 El E D Ll El Ll <br /> Piping Sump#2 X D E 11 El El D El <br /> Piping Sump#3 X [I El E Ll D El El <br /> Dispenser Sump#1&2 x El El Li E El Ll 11 <br /> Dispenser Sump#3&4 X El Ll El 11 Ll 11 El <br /> 6 Dispenser Sump#5&6 X Ll 11 ❑ El E [I El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Test Fluid Supplied and recovered for reuse by,R&D Compliance Testing. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature- 1900radi� Date: June 19,2017 <br />